C11.0 Insurance Policy Changes

ICD-10 C11.0 is officially defined as "Malignant neoplasm of superior wall of nasopharynx." code C11.0 is referenced in 22 tracked payer policy changes from Independence Blue Cross, Excellus BlueCross BlueShield, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code C11.0 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Independence Blue Cross · Effective Aug 25, 2025High impact
08.02.23, Tislelizumab-jsgr (Tevimbra®)
Independence Blue Cross published a new medical policy (08.02.23b) establishing coverage criteria for tislelizumab-jsgr (Tevimbra®), a PD-1 monoclonal antibody immunotherapy. The policy covers multiple cancer indications with specific medical necessity criteria, including anal carcinoma, appendiceal neoplasms, chronic lymphocytic leukemia, colon cancer, endometrial carcinoma, esophageal cancers, gastric cancer, head and neck cancers, hepatocellular carcinoma, Hodgkin lymphoma, rectal cancer, and small bowel adenocarcinoma. Billing teams must implement this policy effective August 25, 2025, ensuring claims are only processed when documented medical necessity criteria are met.
Independence Blue Cross · Effective Oct 1, 2026Medium impact
MA08.173b, Tislelizumab-jsgr (Tevimbra®)
Independence Blue Cross Medicare Advantage added ICD-10 code C78.32 (Secondary malignant neoplasm of pharynx) to policy MA08.173b for tislelizumab-jsgr (Tevimbra®) coverage effective 10/01/2026. This expands the conditions for which this immunotherapy drug is covered under Medicare Advantage plans.
Independence Blue Cross · Effective Oct 1, 2026Medium impact
08.02.23b, Tislelizumab-jsgr (Tevimbra®)
Independence Blue Cross updated policy 08.02.23b for Tislelizumab-jsgr (Tevimbra®) to add ICD-10 code C78.32 (Secondary malignant neoplasm of pharynx) effective October 1, 2026. This is a coding update that expands the diagnosis codes for which this immunotherapy drug is covered under the policy's existing medical necessity criteria.
Independence Blue Cross · Effective Jun 1, 2026Medium impact
MA08.186a, Penpulimab-kcqx
Independence Blue Cross Medicare Advantage policy MA08.186b expands coverage for penpulimab-kcqx to include three new cancer indications (anal carcinoma, appendiceal cancers, and small bowel adenocarcinoma) effective June 1, 2026, and revises head and neck cancer criteria per FDA and NCCN guidelines. Billing teams must add 13 new ICD-10 diagnosis codes and update prior authorization and coverage criteria in billing systems.
Independence Blue Cross · Effective Dec 29, 2025Medium impact
MA08.186, Penpulimab-kcqx
Independence Blue Cross published MA08.186b effective 12/29/2025, establishing new coverage criteria for penpulimab-kcqx (an immunotherapy drug) across multiple cancer types including anal carcinoma, appendiceal cancers, and nasopharyngeal carcinoma. This is a new pharmacy policy requiring billing teams to verify medical necessity criteria are met before processing claims, using unclassified drug codes C9399 or J3590.
Independence Blue Cross · Effective Dec 29, 2025Medium impact
08.02.42, Penpulimab-kcqx
Independence Blue Cross published version 08.02.42b of their Penpulimab-kcqx coverage policy, effective 12/29/2025, establishing medical necessity criteria for this immunotherapy drug across anal carcinoma, appendiceal cancers, and head and neck cancers (nasopharyngeal carcinoma). The policy specifies coverage conditions including required genetic markers, prior treatment history, disease stage, and performance status thresholds. Billing teams must understand these criteria to support prior authorization requests and ensure claims meet coverage requirements.
Excellus BlueCross BlueShield · Effective Nov 16, 2025Medium impact
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy 6.01.12
Excellus BlueCross BlueShield stereotactic radiosurgery and stereotactic body radiation therapy medical policy 6.01.12 has a current effective date of November 16, 2025. Its October 16, 2025 annual review removed life expectancy criteria from the policy criteria. SRS is considered medically appropriate for specified benign, brain and neurologic indications, SBRT is considered medically appropriate for specified extracranial cancers and oligometastatic disease, and SBRT is considered not medically necessary for indications including extrahepatic bile duct cancer, gallbladder cancer and chronic pain.
Independence Blue Cross · Effective Aug 25, 2025Medium impact
MA08.173, Tislelizumab-jsgr (Tevimbra®)
Independence Blue Cross has published MA08.173b, a new Medicare Advantage policy establishing coverage criteria for tislelizumab-jsgr (Tevimbra®), a PD-1 checkpoint inhibitor immunotherapy. The policy covers the drug for multiple cancer types (anal, appendiceal, CLL/SLL, colon, endometrial, esophageal, gastric, head and neck, nasopharyngeal, hepatocellular, Hodgkin lymphoma, rectal, and small bowel adenocarcinoma) as monotherapy or in combination regimens, subject to specific medical necessity criteria including genetic/mutational status, prior treatment history, and performance scores. Billing teams must implement this coverage policy effective 08/25/2025.
Aetna · Effective Aug 5, 2025Medium impact
Penpulimab-kcqx (CPB 1080, reviewed 2026-04-15)
Aetna requires precertification for penpulimab-kcqx under commercial medical plans and considers it medically necessary for nasopharyngeal carcinoma and for appendiceal neoplasms and cancers used as a single agent for dMMR/MSI-H tumors or POLE/POLD1 mutation with an ultra-hypermutated phenotype. For nasopharyngeal carcinoma, the criteria cover first-line use with cisplatin or carboplatin and gemcitabine for six cycles followed by single-agent use, or single-agent use after progression on platinum-based chemotherapy and at least one other prior line of therapy. Members who have had disease progression on PD-1 or PD-L1 inhibitor therapy are not eligible, all other indications are experimental, investigational, or unproven, and continuation is covered for up to 24 months when there is no unacceptable toxicity or disease progression.
Aetna · Identified Oct 13, 2026Medium impact
Toripalimab-tpzi (Loqtorzi) (CPB 1049, reviewed 2026-10-05)
Aetna considers toripalimab-tpzi (Loqtorzi) medically necessary for initial approval in anal carcinoma, appendiceal neoplasms and cancers, colorectal cancer, nasopharyngeal carcinoma, non-small cell lung cancer and small bowel adenocarcinoma when the criteria in the policy are met, and considers all other indications experimental, investigational, or unproven. Continuation of therapy is considered medically necessary for up to 24 months total in nasopharyngeal carcinoma and non-small cell lung cancer, and for up to 13 cycles total for neoadjuvant NSCLC, when there is no evidence of unacceptable toxicity or disease progression. Precertification of Loqtorzi is required of all Aetna participating providers and members in applicable plan designs.
Aetna · Identified Oct 8, 2026Medium impact
Docetaxel (CPB 0956, reviewed 2026-10-05)
For commercial medical plans, docetaxel (Beizray, Docivyx, Taxotere, or generic docetaxel) is considered medically necessary for the listed cancer indications, including breast cancer, non-small cell lung cancer, prostate cancer, gastric cancer, head and neck cancer, ovarian cancer, small cell lung cancer, and soft tissue sarcoma. Breast cancer requires the disease-status criteria stated in the policy, and continuation of therapy is considered medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen. All other indications are considered experimental, investigational, or unproven.
Aetna · Identified Aug 19, 2026Medium impact
Brachytherapy (CPB 0371, reviewed 2026-05-20)
Aetna considers brachytherapy medically necessary for breast, esophageal, eye tumors, genitourinary cancers other than bladder, gynecologic, head and neck, respiratory and digestive tract, and soft tissue sarcoma indications when the EviCore Healthcare Radiation Therapy Clinical Guidelines criteria are met. It also considers brachytherapy medically necessary for skin cancer where surgical resection and photon or electron beam techniques are contraindicated, and for stenotic obstruction after lung transplantation refractory to other treatments. Brachytherapy for bladder cancer, bone metastases, brain tumors, leukemia, lymphoma, multiple myeloma, pancreatic cancer, keloids, palmoplantar pustulosis, spinal tumors and spinal metastases, and subfoveal choroidal neovascularization secondary to age-related macular degeneration is considered experimental, investigational or unproven, and electronic brachytherapy is considered experimental, investigational or unproven for breast cancer and all other indications.
Aetna · Identified Aug 18, 2026Medium impact
Toripalimab-tpzi (Loqtorzi) (CPB 1049, reviewed 2026-08-10)
Aetna's Clinical Policy Bulletin 1049 covers toripalimab-tpzi (Loqtorzi) for commercial medical plans, and Medicare criteria are in a separate Medicare Part B policy. Precertification of Loqtorzi is required of Aetna participating providers and members in applicable plan designs, and the Site of Care Utilization Management Policy applies. Aetna considers the drug medically necessary for initial approval in anal carcinoma, appendiceal neoplasms and cancers, colorectal cancer, nasopharyngeal carcinoma, non-small cell lung cancer, and small bowel adenocarcinoma, each under the criteria listed for that indication, and considers all other indications experimental, investigational, or unproven. Members are not eligible when they have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy. Continuation of therapy is considered medically necessary for up to 24 months total for nasopharyngeal carcinoma first-line therapy and for NSCLC, for up to 13 cycles total for neoadjuvant NSCLC, and for other listed indications when there is no evidence of unacceptable toxicity or disease progression.
Aetna · Identified Aug 18, 2026Medium impact
Tislelizumab-jsgr (Tevimbra) (CPB 1057, reviewed 2025-12-05)
Aetna Clinical Policy Bulletin 1057 sets the commercial medical coverage criteria for tislelizumab-jsgr (Tevimbra). Aetna considers it medically necessary for several cancers under indication-specific criteria, including subsequent treatment of metastatic anal carcinoma, esophageal and esophagogastric junction cancer, HER2-negative gastric adenocarcinoma, metastatic nasopharyngeal cancer, hepatocellular carcinoma, and histologic (Richter) transformation to diffuse large B-cell lymphoma. It also covers MSI-H, dMMR, or POLE/POLD1 ultra-hypermutated small bowel, colon, appendiceal, and rectal adenocarcinomas under the stated criteria, and considers all other indications experimental, investigational, or unproven.
Aetna · Identified Aug 18, 2026Medium impact
Temsirolimus (Torisel) (CPB 0873, reviewed 2025-10-09)
Aetna considers temsirolimus (Torisel or generic temsirolimus) medically necessary as a single agent for subsequent treatment of locally advanced, recurrent, or metastatic endometrial carcinoma, for relapsed or refractory mantle cell lymphoma, and for advanced renal cell carcinoma. It also considers it medically necessary for specified soft tissue sarcoma subtypes, for rhabdomyosarcoma (maximum 12 cycles, with cyclophosphamide and vinorelbine), and for subsequent treatment of advanced, recurrent/metastatic, or inoperable PEComa in uterine sarcoma. Aetna considers all other indications experimental, investigational, or unproven, and considers continuation of therapy medically necessary when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.
Aetna · Identified Aug 17, 2026Medium impact
Hematopoietic Cell Transplantation for Solid Tumors in Adults (CPB 0811, reviewed 2025-12-03)
Aetna's Clinical Policy Bulletin 0811 considers autologous or allogeneic hematopoietic stem cell transplant, both ablative and non-myeloablative, experimental, investigational, or unproven for the following adult solid tumors: bile duct (cholangiocarcinoma), breast, central nervous system tumors, cervix, colon, esophagus, fallopian tube, gallbladder, kidney, liver, lung, melanoma, nasopharynx, neuroendocrine tumors, pancreas, paranasal sinus, prostate, rectum, soft tissue sarcomas, stomach, thymus, thyroid, tumors of unknown primary origin, and uterus. Aetna considers autologous hematopoietic stem cell transplant medically necessary in young adults with primitive neuroectodermal tumors, medulloblastoma, and Ewing sarcoma family of tumors when criteria are met in CPB 0496.
Aetna · Identified Aug 15, 2026Medium impact
Carbogen Inhalation Therapy (CPB 0428, reviewed 2026-07-09)
Carbogen inhalation therapy (5% carbon dioxide and 95% oxygen) is considered experimental, investigational, or unproven for bladder cancer, central retinal artery occlusion, cervical cancer, fracture healing, head and neck cancers, optic nerve damage or degeneration, prostate cancer, retinal artery occlusion, seizures, stroke, and sudden hearing loss. The policy lists no specific CPT or HCPCS code for carbogen inhalation therapy, and the ICD-10 diagnosis codes for these indications are listed as not covered for carbogen inhalation therapy. The policy was last reviewed 07/09/2026.
Aetna · Identified Aug 13, 2026Medium impact
Dostarlimab-gxly (Jemperli) (CPB 0993, reviewed 2026-01-27)
For commercial medical plan members, Aetna considers dostarlimab-gxly (Jemperli) medically necessary under its initial approval criteria for several mismatch repair deficient or microsatellite instability-high cancers, including endometrial, ampullary, breast, colorectal, esophageal, gastric, ovarian, pancreatic, small bowel and anal cancers. It also considers Jemperli in combination with pemetrexed and platinum chemotherapy for first-line metastatic nonsquamous non-small cell lung cancer without genomic aberrations. Members are not eligible when they have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy, and all other indications are considered experimental, investigational, or unproven.
Aetna · Identified Aug 13, 2026Medium impact
Durvalumab (Imfinzi) (CPB 0917, reviewed 2026-06-25)
Aetna considers durvalumab (Imfinzi) medically necessary for commercial medical plans when the criteria for a listed indication are met, and considers all other indications experimental, investigational, or unproven. Precertification is required of all Aetna participating providers and members in applicable plan designs, and Aetna considers members not eligible for Imfinzi when they have experienced disease progression while on PD-1 or PD-L1 inhibitor therapy. Continuation of therapy is medically necessary when there is no evidence of unacceptable toxicity or disease progression on the current regimen, up to 12 months total for unresectable stage II or III NSCLC and up to 24 months total for limited stage SCLC.
Aetna · Identified Aug 13, 2026Medium impact
Paclitaxel, Albumin-Bound (CPB 0834, reviewed 2026-05-28)
Aetna considers albumin-bound paclitaxel (Abraxane or generic albumin-bound paclitaxel) medically necessary for the cancers listed in its initial approval criteria, including Kaposi sarcoma, breast cancer, cutaneous melanoma, endometrial carcinoma, ovarian, fallopian tube and primary peritoneal cancer, biliary tract cancers, non-small cell lung cancer, pancreatic adenocarcinoma, small bowel adenocarcinoma, uveal melanoma, ampullary adenocarcinoma, cervical cancer, bladder cancer and vaginal cancer, when each cancer's stated criteria are met. All other indications are considered experimental, investigational, or unproven, including small cell lung cancer, prostate cancer, soft-tissue sarcoma and gastric cancer. Continuation of therapy is medically necessary for an approved indication when there is no evidence of unacceptable toxicity or disease progression on the current regimen.
Independence Blue Cross · Effective Oct 1, 2026Low impact
08.02.42b, Penpulimab-kcqx
Independence Blue Cross updated policy 08.02.42b for Penpulimab-kcqx effective 10/01/2026, adding ICD-10 code C78.32 (secondary malignant neoplasm of pharynx) to the covered diagnosis codes. This is a coding update that expands the policy's diagnostic scope for this immunotherapy drug used in various cancer treatments.
Aetna · Identified Nov 4, 2026Low impact
Microwave Thermotherapy (CPB 0682, reviewed 2026-10-26)
Aetna's Microwave Thermotherapy policy (CPB 0682) was reviewed on 2026-10-26, and the source does not state what changed or give a new effective date. It covers microwave thermotherapy as medically necessary only for T1 renal lesions, medically inoperable non-small cell lung cancer lesions under 3 cm, and hepatocellular carcinoma tumors of 3 cm or less, and it lists many other uses (such as breast, pancreatic, bladder, and chronic pain indications) as experimental, investigational or unproven.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code C11.0?

There are 22 tracked policy changes affecting code C11.0, including updates from Independence Blue Cross, Excellus BlueCross BlueShield, Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code C11.0?

Payers that have issued tracked updates for code C11.0 include: Independence Blue Cross, Excellus BlueCross BlueShield, Aetna.

How do I get notified when code C11.0 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code C11.0. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for code C11.0?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

All billing codes J3590 C9399 J3490 99215 99213 99202

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08.02.23, Tislelizumab-jsgr (Tevimbra®)

MA08.173b, Tislelizumab-jsgr (Tevimbra®)

08.02.23b, Tislelizumab-jsgr (Tevimbra®)

MA08.186a, Penpulimab-kcqx

MA08.186, Penpulimab-kcqx

08.02.42, Penpulimab-kcqx

Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy 6.01.12

MA08.173, Tislelizumab-jsgr (Tevimbra®)

Penpulimab-kcqx (CPB 1080, reviewed 2026-04-15)

Toripalimab-tpzi (Loqtorzi) (CPB 1049, reviewed 2026-10-05)

Docetaxel (CPB 0956, reviewed 2026-10-05)

Brachytherapy (CPB 0371, reviewed 2026-05-20)

Toripalimab-tpzi (Loqtorzi) (CPB 1049, reviewed 2026-08-10)

Tislelizumab-jsgr (Tevimbra) (CPB 1057, reviewed 2025-12-05)

Temsirolimus (Torisel) (CPB 0873, reviewed 2025-10-09)

Hematopoietic Cell Transplantation for Solid Tumors in Adults (CPB 0811, reviewed 2025-12-03)

Carbogen Inhalation Therapy (CPB 0428, reviewed 2026-07-09)

Dostarlimab-gxly (Jemperli) (CPB 0993, reviewed 2026-01-27)

Durvalumab (Imfinzi) (CPB 0917, reviewed 2026-06-25)

Paclitaxel, Albumin-Bound (CPB 0834, reviewed 2026-05-28)

08.02.42b, Penpulimab-kcqx

Microwave Thermotherapy (CPB 0682, reviewed 2026-10-26)

What insurance policy changes affect code C11.0?

Which payers have updated policy for code C11.0?

How do I get notified when code C11.0 policy changes?

Why do payers change policies for code C11.0?